Deficiency in Conducting Fire Drills at Unexpected Times
Summary
The facility failed to ensure that fire drills were conducted at unexpected times and under varying conditions, as required by the 2012 NFPA 101: Life Safety Code. Specifically, the document review revealed that in six out of twelve fire drills, the condition that caused the simulated fire drill and fire alarm activation was not documented. Additionally, the fire drills were conducted at similar times across different shifts, with three out of four morning shift drills occurring around 10:00 AM and all four night shift drills occurring between 11:00 PM and 6:15 AM. Furthermore, the fire drill logs from the past year did not include the scenarios simulated during the drills, making it impossible to determine if the drills were conducted under varying conditions. This lack of documentation and variation in drill timing was acknowledged by the facility's Administrator and owner during the exit interview. The failure to conduct fire drills at unexpected times and under varying conditions, as well as the lack of detailed documentation, constitutes a deficiency in compliance with the NFPA 101 standards.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 Pine (NAME) Center for Rehabilitation and Healthcare provides the following Plan Of Correction: 1. No residents were affected by the deficient practice. 2. All residents have the potential to be affected by the deficient practice. 3. The EVS Director will conduct fire drills along with scenarios for each fire drill on all three shifts and alternate the times within the shifts, as well as the dates within the month. 4. The Administrator will review with the EVS Director the proposed times and dates of the fire drill to ensure the randomization of the dates and times that the fire drills are being conducted. 5. The Administrator will review the fire drill log book on a quarterly basis to ensure fire drills have been scheduled/conducted on random times/dates. 6. The Administrator will report the findings of his quarterly fire drill audit at the quarterly QA/QAPI meeting. 7. The Administrator and EVS Director will be responsible for the correction of this deficiency.
Penalty
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